Many articles about diabetes appear daily, many of them very interesting. The intent here is to make some of these available for others who may not see them or have bypassed them. I will try to comment briefly on those I have grouped or on an individual article. This is not guaranteed to be a daily post, but I hope that this will give you ideas for your own research or blog posts. Please talk to your doctor about medical problems.

17 October 2013

Again, when something is needed, we see the primary care
physicians (PCPs) lining up against them and in states with strong
medical boards, they are being prevented from coming into existence.
I am talking about urgent care centers (UCCs). With the shortage of
primary care physicians, the strain on most hospital emergency
departments (ED), and rising health care costs, these urgent care
centers operate as a great convenience to non-emergency cases.

Since PCPs do not have evening office hours, this only
seems reasonable that UCCs can fill a great need in caring for people not needing the
services of the ED. In addition, costs are less than the ED. The
PCPs are claiming that this is hurting their people and safety is an
issue. Some providers believe urgent care centers disrupt
coordination and continuity of care. I say to these providers, then
have practices that are open 16 hours per day, 7 days a week and
there would not be the need for UCCs.

Others believe the concerns of PCPs may be overstated, given
urgent care’s focus on episodic and simple conditions rather than
chronic and complex cases. In the future, health coverage expansions
under the national health reform may lead to greater capacity strains
on both primary and emergency care, causing even more growth of
urgent care centers. Hospitals view urgent care centers as a way to
gain patients, while health plans see opportunities of containing
costs by steering patients away from costly emergency department
visits.

UCCs are not designed to handle car accidents or resuscitate
patients at death's door, but they do treat minor injuries such as
cuts and minor fractures, as well as the ear infections and strep
throats of primary care. The Urgent Care Association of America puts
the number of UCCs at 9000, with physicians or physician groups
owning 35% of them. In addition, corporations own 30%, hospitals own
25%, and non-physician individuals or franchisors own 7%.

Rapid expansion of UCCs is often attributed to such factors as
long wait times for primary care appointments, crowded emergency
departments and patient demand for more accessible care, including
after-hours appointments. UCCs provide care on a walk-in basis,
typically during regular business hours, as well as evenings and
weekends, though not 24 hours a day. UCCs commonly treat conditions
seen in primary care practices and retail clinics, including ear
infections, strep throat and the flu, as well some minor injuries,
such as lacerations and simple fractures.

UCCs generally are not equipped to deal with trauma, provide
resuscitation or admit patients to a hospital, all reasons for
seeking ED care. UCCs are typically staffed by physicians, generally
with backgrounds in primary care or emergency medicine, and some have
nurse practitioners or physician assistants working under physician
supervision.

Patient demand for more convenient access to care reportedly has
increased, prompting renewed growth in urgent care centers.
According to a recent study, approximately 60 percent of patients
with a usual primary care physician (PCP) reported that their PCP
practices do not offer extended hours, suggesting a niche for urgent
care centers to fill.

16 October 2013

Yes, this goes without saying. The actions of our pharmaceutical
manufacturers is almost criminal, no it is criminal. I say this
because once the drug is approved for one use; the drug reps are
promoting it heavily for “off-label” uses. Then they get FDA
approval for these “off-label” uses and doctors happily promote
their use and even have the philosophy that more is better.

This blog by Dr. Kenneth Lin, carefully lays out how
pharmaceutical manufacturers convince doctors to overuse many drugs
often to the harm of patients. He uses two common drugs that this
has happened to, anemia drugs (Epogen, Procrit, and Aranesp, which
mimic the actions of the hormone erythropoietin) and the diabetes
drug rosiglitazone (Avandia). These two drugs were featured in
recent articles by Peter Whoriskey in the Washington Post. The
anemia drugs were developed to spare dialysis patients with severe
anemia the inconvenience and risks associated with periodic blood
transfusions.

Whoriskey also found that pharmaceutical companies moved
aggressively to put these drugs into use in a far greater patient
population, including those less likely to benefit from them.

“The trouble would arise as the drug makers won FDA approval
for vastly expanded uses, pushing it in larger doses, for milder
anemia and for patients with a wider array of illnesses. Very
quickly, the market included nearly all dialysis patients, not just
the roughly 16 percent who required blood transfusions. The size of
average doses would more than triple. And over the next five years,
the FDA would approve it to treat anemia in patients with cancer and
AIDS, as well as those getting hip and knee surgery.”

Doctors became motivated to give more doses of these drugs because
the pharmaceutical companies were offering greater incentives,
estimated between $100,000 and $300,000 annually for an oncologist.
This created a seductive atmosphere and caused doctors to think if
some of the drug was good, more had to be better. No checks were
done and over prescribing continued.

“Not until 14 years later did an independent researcher
obtain access to the complete study report from the FDA and conclude
that the NEJM authors had used statistical slight-of-hand to
obscure an increased risk of heart attacks and death in the
normal-hematocrit group. In the meantime, lobbyists working for the
drug manufacturers successfully blocked efforts by Medicare
administrators to stop paying for the higher (harmful) doses.”

This was the same tactic used by Glaxo Smith Kline in their
promotion of Avandia and the manufacturer successfully stalled
regulatory action in the US for three years, during which thousands
of new patients were prescribed the drug.

This leads to the conclusion that the role of FDA members were to
blame and let huge conflicts of interest stand in the way of
protecting the public. The system of rotation from FDA to the
pharmaceutical industry and them back to the FDA needs to stop and
this should be outlawed with severe penalties for employees that do
this. The next issue is passing a law that pays the salary of the
FDA employees and pays for the supplies and operations to prevent
pharmaceutical companies from having to kick in large sums of money
to pay for the approval of their drugs. This practice also needs to
be against the law with larger fines levied. These fines should be
large enough to prevent companies from bribing FDA officials.

15 October 2013

Hospital protocols do hinder and actually harm patients. I had a
hard time believing the first part of this doctor's blog until I
realized he was not joking. My next thought was why a hospital would
treat a doctor in this manner. I would have guessed that a doctor
and even a doctor's family would be expressed to the head of the
line. I am happy to see that they receive the same poor treatment as
the rest of us.

It is a shame that a few patients have required the need for
hospitals to enforce strict protocols such as name and personal
information before treatment can start. I understand the need for
medical information to avoid allergic reactions and medical
complications with medications the person is already taking. Yet,
patients often arrive unconscious and unable to communicate and they
are treated. I can appreciate the need for triage as the most
serious patients should go to the head of the treatment line and that
should never be disputed. Even this gets complaints from those that
feel they are totally privileged and better than the rest.

In a way, it is probably the most fun way to spend a day sitting
in an emergency department. It is surprising what happens and does
not happen. This happened by accident one day when my daughter
injured herself and my wife had taken her to the emergency
department. I got there as soon as I was notified, but was refused
to see my daughter because she was in treatment. After treatment was
completed, I did not see my wife and daughter being moved to the
hospital room since the exit used by patients was not visible from
the waiting area, which I had been moved into.

This was before cell phones. There were mobile phones, but few
people could afford them. So there I was, probably less than 40 feet
from my wife and daughter and unable to have anyone look for them.
In some ways, this seemed to be a hospital trick to keep families
separated. Finally two of us decided to leave the emergency
department and go into the hospital since we had not seen any of our
families leave. Yes, both of our families had members admitted and
we were not notified. For some reason they would admit that my
daughter had been admitted to the hospital, but would not tell me
which room. If it were not for my wife entering the hallway and upon
seeing me, coming to get me, neither of us would have known. It
turned out that his wife was in the same room as my daughter.

After some time we were able to convince our wives that we had
been there since before noon and been told that we would see them
later. The other fellow even guessed that they had been told that
they would be informed when we arrived. I finally had to take my
wife and his son down to show them the room where we had been kept.
Still waiting were five other people that had been there at the time
we were there. My wife knew one of the individuals and where his son
was in the hospital and the rest were advised to start looking
elsewhere in the hospital.

At that point, a nurse came by and asked that everyone be seated
and quiet. I am afraid I was less than polite when I asked why we
were being denied access to our families. I was told that they did
not want too many people in the exam rooms. I said that we were
still kept in the dark when our families were moved into the
hospital. They were told they would be notified when we arrived,
when we had been here for some time. At that point one of the
doctors walked by and could tell we were very upset. He wanted to
know what was happening. My wife spoke up and said the nurses were
causing family stress by separating us from our families. Instead of
notifying us when discharged from the ER or admitted to the hospital,
those that had been diverted to this room were not informed.

One of those was an executive for a large area corporation and
large employer and said that all contributions to this hospital would
stop immediately. Several others wanted to know who was responsible
for this and that the nurses on duty should all be removed from their
jobs. To this, I added the nurses that would not tell us where our
families were in the hospital. The doctor finally got quiet and
called the administrator to the room. It took another hour to sort
things out and supposedly get protocols corrected. The executive
said that he was sticking by his word since people were not being
held accountable for the mess and with the attitude of the staff
could not be ignored. The administrator wanted a private meeting,
but the executive said this would be an attempt to hide things from
these families. Everyone was taken to the nurse station to find out
if their relatives were admitted and even with the administrator
telling them to get the information; it took almost 30 minutes, as it
was clear, they were dragging their feet.

The local newspapers were notified and six months later, the
hospital was sold to another hospital and policies changed. It was
fortunate that our family did not need to use that hospital again and
moved to another town about four months later.

I would encourage everyone to read the blog by the doctor here and
another doctor about that doctor's blog here. It is a shame the
protocols established by some hospitals cause more stress and harm to
families than good will.

14 October 2013

Before getting into this blog, I would like to include some points
that the World Health Organization (WHO) has in their guidelines
about assessing the value of a screening test.

#1. The condition should be an important health problem.
#2. There should be a treatment for the condition.
#3. Facilities for diagnosis and treatment should be available.
#4. There should be a latent stage of the disease.
#5. There should be a test or examination for the condition.
#6. The test should be acceptable to the population.
#7. The natural history of the disease should be adequately
understood.
#8. There should be an agreed policy on whom to treat.
#9. The total cost of finding a case should be economically
balanced in relation to medical expenditure as a whole.
#10. Case finding should be a continuous process, not just a
“once and for all” project

The above are guidelines worthy of remembering and applying to
many topics about screening. In the US, professional medical
organizations and government agencies are making the determination of
what screenings should be accomplished and many times when they are
to be done. In my research, I have not discovered where the WHO says
to harm patients to do the screening, create a stereotype that
mandates screening, or order very costly screening for the sake of
screening with little or no scientific evidence to back the
screening.

Yet we have screenings happening based on the three items
mentioned above that professional organizations and government
agencies think need to be done. Other types of screening are not
done because government is not mandating them and many of the doctors
would not be current enough to know what to do if the screening
result was positive.

The latest screening being mandated seems to be for dementia.
This screening includes all types. I have to agree with one author
that many of these screenings are poorly designed, poorly thought
through, and often damaging or harmful to the frailest patients.
However, with the government behind this and several of the medical
associations, this will be difficult to stop.

11 October 2013

As more of us people with diabetes are told to eat more fresh
produce, our supermarkets know that we are looking for fresh produce.
Even then, the produce is several days old and not truly fresh as
the grocery chains would like us to believe. Three or more days old
are not fresh any longer. What are we to do if we don't live on an
acreage and do our own gardening?

I wish I could do just that and be able to garden, but apartment
living does not allow this to happen. Even the owner of the building
won't allow gardening in the manicured lawns. No one near us will
allow gardening and this means traveling to surrounding farms, which
even many of them don't want. I finally located one farmer where we
can get fresh eggs and some produce during the summer, but not enough
to satisfy a family of two. Plus, the selection is limited to what
they don't or can't process and not what some of our choices would
include. This means no beans, no peas, and many other of my choices
of vegetables. Plus many of the selections are past their prime when
we are notified to come and harvest.

May I am just used to too many years of good fruits and vegetables
harvested at their prime and canned or frozen beyond what we consumed
in our daily meals. Mother and Dad always planned the plantings to
spread out the harvest and prolong what we had fresh for the daily
meals. Plus the canner was always kept busy once harvest started and
the prime picking was for the daily meals or frozen.

This article was a pleasant surprise to find; however, many will
not gain from this, but still is an interesting article even with the
hazards it brings out. The concept of local food and urban gardening
is gaining popularity as urban agriculture, with its benefits and
obstacles, and is coming to many cities.

“The benefits of urban agriculture are many. Urban gardens
are often built on previously unused lots, increasing the beauty and
value of the neighborhood. They provide recreation opportunities and
a social network for the gardeners involved. Urban food production
also means that healthy, fresh produce is readily available to city
dwellers.”

The challenges that organizers and growers face need to be
understood and conquered if urban gardens are to take hold and even
be profitable. Many of the obstacles, planners and growers face
include soil contaminants, water availability, and changes in climate
and atmospheric conditions.

Of the contaminants found in urban soils, lead is the most
prevalent. Even though there is concern about plants taking up lead
from the soils, research shows plants take up very little and in
fact, it is less than we are exposed to from drinking water.
Practices such as washing food before eating and covering soils with
mulch can decrease these risks. Finding reliable and safe water
sources can be difficult for urban gardeners. Using drip irrigation
that will deliver water where and when it is needed can conserve
water.

I find I have no trouble in discussing any of the above or more,
but studies show that they are often difficult for providers and
patients to talk about and many just won't consider talking about
them.

The first item above is important for both men and women with
diabetes for a variety of reasons. Men often have sexual dysfunction
or erection dysfunction quite often and this can affect how they feel
about diabetes. In looking for studies, there are a few, but not
worth the time because most are less than 10 men. Women have other
problems and often dislike having sex because of yeast infections and
often dryness making sex painful.

The second item above is very difficult to get providers to talk
about because often they are not totally aware of what the actual
costs are when providers are employed by the hospital. Hospitals
have so many extras that are tacked on to a charge to get more from
the insurance companies and/or Medicare/Medicaid. There are at least
three free apps, which address health care costs.

The third item above is more difficult for patients because they
are afraid of the reactions they will receive from their provider.
Once the diagnosis is received by the patient, some will consider
having the treatment prescribed by their provider, but others would
like to consider complimentary treatment, which may include holistic,
neuropathic, or homeopathic regimens. Often they won't discuss these
with the doctor because they know from past experience that the
doctor will ridicule them and dismiss the treatment. Often they just
take the prescription or prescribed treatment and go to another
doctor that will provide these.

The fourth item above is probably one of the more contentious
topics as many providers just hand out papers to have the patient
check the boxes for the advance directives for end of life care to
meet federal mandates. In these situations, many patients just
ignore these. If they are like me, I have seen physicians,
hospitals, and families ignore the wishes of the patient and do what
they want done, even with the advance directives on file. I have
even seen family ushered out of a parent's room so they can follow
their own policies against the directives.

The fifth and final item above is about mobile technologies.
These can improve the doctor-patient relationship, but even then,
doctors do not want them around and will ignore their use. Many
patients use the internet and this often causes physicians to see
this as a threat to them and upsetting the balance of their
relationship with the patients. Fortunately, times are changing and
with both shared decision making and digital health technology in
present popularity, physicians are often forced to deal with this or
lose patients.

Now it becomes necessary to state that both providers and patients
need standards that medical app developers can follow. If they are
reliable and effective digital tools, they can help prevent the
elephants from being in the exam room discussion instead of making
the elephants presence larger.

While the above discussion may not include all the elephants,
often once they are recognized and the provider brings them up with
the patient, they disappear and the tension is relieved. Often a
partner or a caregiver can be the one to start the conversation and
they can be the ones to carry these discussions. Read a doctors
interpretation and thoughts about this topic here.

09 October 2013

You may wish to skip this blog. This is because I am overly
critical of another blogger. I normally respect this blogger and she
has much good to say, but that was not my take on this blog.

Again, I wonder why is it that doctors misunderstand
communications. Every doctor has his/her interpretation of patient
engagement. Now I will add the term “meaningful use” to patient
engagement and say that most doctors are trying to hide behind the
two phrases and are not concerned about communications with the
patient. To quote Dr. Rob Lamberts, “Communication
isn’t important to health care, communication
is health care. Care is not a
static thing, it is the transaction of ideas. The patient tells me
what is going on, I listen, I share my thoughts with the patient (and
other providers), and the patient uses the result of this transaction
for their own benefit.”

I respect the definition by Dr. Lamberts, but anything in other
definitions is bull, and the quicker we as patients understand this,
the better off we will be. I covered his blog that Dr. Leslie Kernisan refers to, but do not understand why she had to muddy the
waters even more. I will quote Dr. Kernisan to show this: “Here’s
my current take: Supporting patient engagement means fostering a fruitful
collaboration in which patients and clinicians work together to help
the patient progress towards mutually agreed-upon health goals.”
Mutually agreed-upon health goals may not always be in the best
interest of the patient.

She says everything but communication as if communication is a
term to be avoided at all costs. Then she uses the term to bring
people back to patient engagement. I quote, “Communication with
patients is, of course, essential to all of this. This is why any
innovation that improves a patient’s ability to access and
communicate with healthcare providers is proudly labeled as “patient
engagement.””

Remember meaningful use, doctors may not meet this if they use
communication instead of meaningful use. Then we find out that Dr.
Kernisan prefers to quantify patient engagement when she states,
“Back to the examples of patient engagement cited above. What
are the “right metrics around what constitutes real patient
engagement”? Obviously, it will be difficult to agree on metrics
if we don’t first agree on the definition.”

Sounds to me she is trying to calculate how to fit this into
meaningful use. Tell me this isn't so, doctor! I am even more
concerned now and have to wonder what it is about the word
communications that doctors are unwilling to accept this, with the
exception of Dr. Lamberts.

I become very uncomfortable when doctors use the term patient
engagement around me and even more when they use the term in surveys
sent out to attempt to get praise for their actions. I refuse to
return these and when one doctor called me to find out why I had not
returned the survey, I am afraid I was not too polite in my response.
I also said that the phrase patient engagement had no standard
meaning and communication was definitely not part of my appointment
other than keeping my mouth closed except to answer questions.

Of course, the doctor disagreed. I asked him who had set the
goals I was to use for my health. When he said we both had, I
reminded him that I had not indicated I approved or disapproved of
the goals he had laid out. I then told him where I disagreed and
why. He quickly asked me to complete the survey and return it. I
said I would and I would send one to the administrator and keep
another copy for my records. “Click” was the next sound and it
was more of a “bang.”

I did return the survey, but he is no longer a doctor on my team
and that is by mutual agreement.

08 October 2013

I am glad someone is speaking out about what providers and the
health information technologies (HIT) are doing to shut us out as
patients. If doctors think that their pedestal is tarnished now,
wait until patients really understand what they are doing and they
may find that there may be some tar and feathers in the next round.
Not only this, but also many doctor-patient relationships may come to
an abrupt end.

Adrian Gropper, MD writes about Health IT Week – the Consumer
Health IT Summit. He does not pull any punches and his blog should
upset a few great doctors that understand the importance of
communication. The rest probably are clapping their hands heartily
and saying Amen.

Dr. Gropper says that the Health IT week demonstrated a double
barrel strategy first to keep patient information segregated from
provider information. Then by rebranding HIPAA as “Meaningful
Consent” with no input from patients, this makes patients
second-class citizens in Meaningful Use Stage 2 interoperability.
Providers and regulators are working together to see that is stays
that way.

Normally providers and IT people make comments, but they are
strangely quiet after this blog. They seem to know that some
patients read many of the blogs and they are careful not to disclose
their opposition to Dr. Gropper telling all. Dr Gropper and several
providers have laid out some of the background in a good discussion.

“The segregation of patient information from “provider”
information is the current federal regulatory strategy. It’s even
more so in the states. By making patients into second-class citizens,
the providers can avoid open scrutiny, transparent pricing, and
independent decision support.”

“Federal regulators then create a parallel system where
information is delayed, diluted, and depreciated by lack of
“authenticity”. This is promoted as “patient engagement”. For
regulators, it’s a win-win solution: the providers support the
regulation that enables their price fixing and many patient advocates
get to swoon over patient engagement efforts.”

What is even more troubling is this. “The Model Notice of
Privacy Practices legitimizes the practice of provider-to-provider
health information exchange under the HIPAA Treatment, Payment and
Operations (TPO) exemption. TPO is used by providers and health
information exchanges to avoid patient authorization for sharing of
private information.” This smacks of patient privacy being
violated with no concern.

Another point made by Dr. Gropper is the intentions for emails
between doctor and patient. Apparently, most providers, regulators,
and HIT companies wish to keep emails out of the hands and use by
patients. Dr. Gropper states that the regulators are making most
emails an organization-to-organization system. This is part of the
regulations for Meaningful Use Stage 2 certification.

This means that the original intent of Blue Button Plus, having
secure communications between patient and provider, will be lost and
transparency will be lost. This will also mean that hospitals and
providers can avoid giving patients an independent decision support
portal and a key independent communication channel.

Without transparency and independent decision support, the tools
for reducing health care cost become limited. The market-based (as
opposed to Medicare for all) foundation of ObamaCare cannot highlight
unwarranted and overpriced services as long as the providers of those
services maintain control of our personal information. This seems a
merely politically expedient. If we accept an impotent Blue Button
Plus and HIE exclusion via TPO we may be headed for a regulatory
failure even larger than the sub-prime mortgage crisis.

Patients need to sharpen their skills and knives for the battle
ahead. It won't be pleasant for all concerned.

07 October 2013

These two studies raise more concerns than they solve. Why are
larger doses of statins needed to reduce the risk of dementia. At
the same time, other studies are finding more muscle and joint
problems with the increased dosage of statins and more cases of type
2 diabetes.

This also raises the issue of which statins were being used by
patient numbers, possible ethnic variables, and the correct dosage to
cause the reduced dementia. I therefore agree with Professor Jose
Gonzalez-Juanatey, University Hospital, Santiago de Compostela,
Spain, who said, "These new data suggest that high-potency
statins may reduce the incidence of dementia in patients with atrial
fibrillation and in elderly patients. Nevertheless, before we can
know for sure that statins may prevent dementia, a clinical trial
confirming these findings is mandatory."

At the same time, Seth S. Martin, MD, Johns Hopkins Hospital,
Baltimore, Maryland, who is conducting a systematic review of the
literature on statins and cognition/dementia, said, “These
current results fit in well with existing studies.”

This leaves things unsaid and especially what conflicts of
interest have not been disclosed. While some statistics are shown
for the different statins in the press release, no patient numbers
are matched to the statins and an attempt to obtain to details of the
two studies was unsuccessful. So I am left wondering who funded the
study?

I am less concerned about these two studies having some solid
evidence and the information not being cooked by Big Pharma than I
was about the information I used in this blog. However, I remain
concerned about conflicts of interest.

04 October 2013

According to this Medpage Today article, YES. This Joslin blog
also raises issues that people with Medicare and diabetes may not be
aware are available. While I don't utilize them personally, some
people may have the need of these services. Others that are in need
of these services may not be able to receive them because of the
shortage of certified diabetes educators in many areas of the US, and
registered nutritionists are also in short supply. The CDEs are
needed for the education and many doctors do not have them available
or will not utilize them.

The medical nutrition therapy is a complementary benefit. You
must be counseled by a registered dietitian or nutrition professional
that is a Medicare provider. In addition, your physician must write
a referral for you to receive this service. You should receive an
individualized nutrition care plan and be monitored for changes in
your diet and laboratory values.

Other preventive services are also funded by Medicare and should
be utilized. My blog here covers this and a link to the list of
preventive services.

The Medpage Today article takes off in another direction and has some
comments that are not too complementary about Medicare. I do agree
with the article that there is a need for public education when it
comes to understanding what Medicare does and does not pay for and
the why. We as Medicare beneficiaries will need to become more
familiar with some of the provisions and reasons Medicare is
tightening the purse strings.

Reform will need to happen and this may become painful in the
pocket of many beneficiaries. I can only hope that the supplemental
policies can cover the holes and not become too exorbitant in doing
so. The following indicates current public opinion and are not
completely on target.

Public opinion polls show that poor government management (30%),
fraud and abuse (24%), and excessive charges by hospitals (23%) were
top reasons voters cited for Medicare's rising costs. The cost of
new drugs and treatments was the lowest-ranked reason, with 6% of
respondents citing it.

Medicare's hospital insurance trust fund will be depleted by 2026
if current spending rates continue, the program's trustees said
earlier this year. I am not sure where the author obtained the 2026,
as I remember, probably incorrectly, the year of 2018 for Medicare to
exhaust its funds under ACA.

“Increasing the public's understanding about how Medicare works,
outside of just how to navigate the program as a patient, could raise
the level public policy debate in the country, the authors said.”
I think with the baby boom generation now increasing in the Medicare
arena, that it is time for a public education campaign to begin.

03 October 2013

According to this article in Medpage Today, the author states that
a study shows emergency department (ED) use could surge under ACA.
This increase will happen under both the newly insured and those
insured under Medicaid.

Causing some of this will be the shortage of primary care
physicians and many states not accepting NPs, PAs, and Pharmacists to
work in the primary care field independently.

Increases in California emergency department (ED) use were driven
in large part by Medicaid patients. The researchers say this will be
a precursor to increased burdens after the Affordable Care Act kicks
in completely.

Many patients who will soon be insured under the ACA will be
enrolled in Medicaid. While these people are generally healthier than
current Medicaid enrollees, they may introduce a new and additional
burden to treat undiagnosed and uncontrolled conditions.

“These costs may represent a bigger picture of burdens on
acute care across the U.S. under expansions to Medicaid under the
ACA, according to David Howard, PhD, at the Department of Health
Policy and Management at Emory University's Rollins School of Public
Health in Atlanta.”

“James McCarthy, MD, of the University of Texas Health
Science Center at Houston, noted that additional healthcare burdens
imposed by the ACA "will result in increased ED utilization in
many markets because of inadequate primary care infrastructures to
support the population."”

These two individuals that were not part of the study, state the
problems patients will face under the Affordable Care Act (ACA).
This is one more reason that I wrote my blog here to warn people
about being careful of changing doctors at the present time. You
don't want to be without a doctor when the problems start and the
newly insured are looking for primary care physicians.

02 October 2013

I admit I am tired of reading about studies involving rodents that
are heralded as a breakthrough. Most often that is the last we hear
about them and then we see no human trials or studies using the
rodent data. To me this means there is no viability for these to
move forward to humans and thus no meaning for the rodent studies
recently heavily promoted.

Now we have two more rodent studies, one about an approved cancer drug that could treat diabetes and another that could potentially
solve the loss of beta cell features that contribute to the onset of
diabetes. Now will we see any human studies confirming these
findings? It will be interesting, but doubtful.

The most interesting is the adapting of the cancer drug and this
is probably the most promising as the researchers do state,
"Anecdotally, there have been reports that diabetic patients
who have been prescribed VEGF inhibitors to treat their cancer are
better able to control their diabetes." They also state,
"Much work remains to translate these mouse studies to human
patients, but it will be interesting to explore VEGF inhibitors or
drugs that can stabilize HIF-2alpha, such as prolyl hydroxylase
inhibitors, for diabetes treatment, possibly in combination with
pre-existing therapies to minimize toxicities."

"Targeting the Phd3/HIF-2 pathway represents a new
therapeutic approach for the treatment of diabetes with little
toxicity," said one of the researchers. "These
studies indicate that Phd specific inhibitors, especially Phd3,
should be more widely developed for clinical development."

The second article about the protein Nkx6.1, which is a beta-cell
enriched transcription factor, is essential for maintaining the
functional state of beta cells. The study shows that loss of Nkx6.1
in mice caused rapid onset of diabetes. Scientists have revealed the
critical role of this protein in the control of insulin biosynthesis,
insulin secretion and beta-cell proliferation.

The researchers have found that the loss of Nkx6.1 activity had an
immediate on the expression of genes that give beta cells their
ability to synthesize and release in insulin biosynthesis.

01 October 2013

Out of the many national topics for the month of October, I
selected just two of the national month of October topics. The first
is National Disability Employment Awareness Month (NDEAM).

In 1945, Congress enacted a law declaring the first week in
October each year "National Employ the Physically Handicapped
Week." In 1962, the word "physically" was removed to
acknowledge the employment needs and contributions of individuals
with all types of disabilities. In 1988, Congress expanded the week to a month and changed the name to "National Disability
Employment Awareness Month." The theme for 2013 is "Because
We Are EQUAL to the Task."

The Office of Disability Employment Policy (ODEP) was established
in 2001 and assumed responsibility for NDEAM. ODEP has worked to
expand its reach, scope, and make this a worthy national event.

This year's theme echoes the message of ODEP's ongoing Campaign
for Disability Employment to promote positive employment outcomes for
people with disabilities. They are striving to expand ideas about
what youths with disabilities can do when they receive encouragement
and support for their ambitions. Conducted in collaboration with
business and disability organizations, the campaign emphasizes that,
at work, it is what people can do that matters.

The second national event is Talk About Prescriptions Month
(TAP Month). As a person with diabetes, prescriptions have
become part of my life. While I don't like many prescriptions, I do
need to take the medications. In reading some of the web sites about
this, I like the fact that some straightforward ideas were presented.

"Too many times, people misuse medications, either by not
following proper use instructions, or not taking them as directed by
their physician, nurse practitioner, or physician assistant. This
misuse often leads to other health problems. That's why NCPIE is
launching the 3Rs for Safe Medicine Use program." Phillip
Schneider, NCPIE Chairman. NCPIE stands for The National Council on
Patient Information and Education and NCPIE

During ”TAP” Month, on October 15, 2013, NCPIE will launch a
new national campaign called the Adherence Action Agenda (The
A3 Project), with a particular emphasis on the need to call attention
to and address improving adherence by Americans suffering from
multiple chronic conditions (MCCs).

This theme was used in a prior year, but still in relevant today.
The 3Rs for Safe Medicine Use, focusing on the following key
safe medicine use messages for consumers and healthcare providers:

Risk: recognize that all medicines (prescription and
nonprescription) have risks as well as benefits; and you need to
weigh these risks and benefits carefully for every medicine you
take.

Respect: respect the power of your medicine and the value of
medicines properly used.

Responsibility: take responsibility for learning about how to
take each medication safely. Being responsible also means following
this important rule: when in doubt, ask first. Your healthcare
professional can help you get the facts you need to use medicines
correctly.

Because most doctors bail on doing this, the pharmacists in many
states are now required by law to provide this information.

The information at this link was last updated in October 2005, but
is as important today as ever. Just understand that many doctors are
listening to drug representatives and you need to be sure that the
doctor has no conflicts of interest for prescribing a medication.
There are some questions that need to be asked of the doctor, but be
careful as some doctors are easily offended by the manner in which
you chose to ask the question.

30 September 2013

Happy – no, but I am glad I questioned the science promoted in
this blog and declared my belief that Big Pharma promoted the article
and maybe even the research and they do not wish to have the results
confirmed or denied. Sorry, but I couldn't accept the information as
it is presented and viewed the information as unreliable and even
possibly a farce.

This study confirms that the science has to be in error and the
information was from less than reliable source. Big Pharma has to
have been promoting it. This Medscape article does declare that
there is a strong link between statins and their cause of cataract
development. “At the recent European Society of Cardiology
(ESC) 2013 Congress , Dr John B Kostis (Rutgers Robert Wood Johnson
Medical School, New Brunswick, NJ) presented the results of a
random-effects meta-analysis, showing a 20% lower rate of cataracts
with statin use compared with no statin use, with a more pronounced
benefit seen when statins were started in younger patients.”
At least they were able to identify Dr. Kostis and his academic
school.

“The meta-analysis published today, however, found the
opposite. It matched 6972 statin users with nonusers within the San
Antonio Military Multi-Market Area health system using propensity
scores based on variables that increased the likelihood of receiving
statins and increased the risk of developing cataracts. Statin users
had to have been on the drugs for more than 90 days; simvastatin
was prescribed in almost three-quarters of the patients.”

The author emphasizes that statins are very effective medications;
therefore, side effects are to be expected. I am glad that this puts
healthcare providers on notice and stresses that they should make
sure there is justifiable indication to prescribed statins. Many
doctors do not follow guidelines to confirm that the potential
benefits outweigh the potential risks of side effects for individual
patients.

The message for patients is one of understanding and that statins
are a tool for treatment of heart disease and should not be stopped
because of a small risk of association with other diseases. It is
wise to commit to lifestyle changes, like stop smoking, and continue
to be physically active than take a pill to lower your risk of heart
disease. Until this can be accomplished, consult with your doctor to
determine if it may be wise to remain on statins.

27 September 2013

What hospitals lobbied too hard to receive and prevent doctors in
practice from receiving may have backfired on them. I say just
deserts for your greed, hospitals. This New York Times article paints the correct picture. I can only call the tactics by
hospitals as bullying tactics, not lobbying. What the Times article
leaves out is the amount of money used to support congressional
backers of the bill that favored the hospitals and now may need to be
repeated. This of course will come out of the pockets of patients
and taxpayers.

At least the Medicare Payment Advisory Commission is seeing the
cost difference created by the hospitals with their “facility fee”
addition to all submissions to CMS. This is done for hospital
outpatient clinics that are part of the hospital and facilities where
the hospital has established clinics by purchasing an entire
physician practice. A physician’s practice that is purchased by a hospital often
stays in the same location and treats the same patients, but Medicare
and Medicare beneficiaries pay more for the same services.

The 17-member Commission uses the following examples to show the
disparities between hospitals and independent physician practices.
An office visit for 15 minutes to an independent physician practice
is reimbursed to the practice for $58 and the patient pays an
additional $14.50 for a total of $72.50. The hospital receives
$98.70 for the same consultation and the patient pays $24.68 for a
total of $123.38 or a combined $50.88 more for the hospital.

Then consider a certain type of echocardiogram, Medicare and the
beneficiary pay a total of $188 when this takes place in an
independent physician practice. The same test done in the outpatient
department of a hospital yields a total cost of $452. The hospital
gains $264 over the physician practice. This hardly seems fair or
justified for the patient.

The USA Today article says a study found that tens of thousands of
times each year, patients undergo surgery they don't need. This
calls for patients to be more vigilant when procedures are
recommended involving surgery. Yes, the author blames doctors that
are bad apples, but often I wonder why patients don't seek a second
opinion.

Yes, patients have part of the responsibility for pushing doctors
to take action for them or their loved one, when in fact, doing
nothing or medically treating a condition may be the better course of
action. Also, consider that the current medical system does provide
incentives to perform a costly procedure instead of medical
management.

As a patient, we need to learn not to be so trusting of our
doctors and seek one or more opinions. The money you spend for that
second opinion may just prevent you from bearing the total cost of
surgery when Medicare or your insurance says it was not necessary and
refuses payment.

26 September 2013

The FDA likes to be embroiled in controversy and they chose to do
it quite regularly recently. This time they choose hyperbaric oxygen
therapy. As is so often the case, what they don’t tell you is more
important than what they do tell you. Yes, they are correct in
issuing the warning as hyperbaric oxygen therapy (HBOT) has not been
clinically proven to cure or be effective in the treatment of cancer,
autism, or diabetes.

What surprises me is the Department of Defense claims. They say
that the will not use HBOT off-label because they claim that they
don't prescribe off-label use of medications and treatments for
veterans. If this were true, then the DoD needs to stop using
off-label antipsychotic drugs to treat traumatic brain injury (TBI)
and post-traumatic stress disorder (PTSD).

In a study conducted in Israel, the use of HBOT helped TBI that
had existed for many years and successfully. Yet the US DoD is
rejecting this help for veterans. Where is our humanity? Oh, right,
it is an off-label use. Yet licensed physicians and healthcare
institutions may legally use an FDA-cleared hyperbaric chamber to
treat unapproved or “off-label” diseases and conditions, though
it is illegal to promote or advertise such uses. A few doctors are
already using HBOT off-label, but not nearly enough of them.

Part of the warning says, “Patients may incorrectly believe that
these devices have been proven safe and effective for uses not
cleared by FDA, which may cause them to delay or forgo proven medical
therapies.” I wonder which proven medical therapies they are
talking about, dangerous drugs and expensive, invasive surgeries?

“This is part of the problem. The FDA tends to protect
therapies that are non-natural and patentable, so that drug companies
can afford to spend $1 billion on average for agency approval.
Bringing these drugs through the approval process pays the agency’s
bills, including salaries. Indeed much of the cost of the FDA is born
directly by drug companies, which creates a huge conflict
of interest.” Bold is my emphasis.

The final bit of information the FDA did not mention in their
warning is that the patents on HBOT ran out years ago. This means
that this therapy will not garner additional use approvals because
the FDA cannot require money for approval. HBOT is a dead issue as
far as FDA is concerned and human suffering can continue.

Congress needs to step in and limit the funds FDA can require for
approvals and put some other restrictions and orders in place to
encourage better actions. Otherwise like HBOT, other projects such
as diabetes test strip accuracy won't be acted on either.

25 September 2013

Who is checking on the people who are minding our elders? While
this is taken from information gathered in California, I know that it
applies to many other states. if not all states. According to a new
policy brief and related report by the UCLA Center for Health PolicyResearch, very little data exists to measure the care or quality of
care provided by private home care providers.

Two of the provider organizations in California, In-Home
Supportive Services (IHSS) and Home Health Agencies are subject to
licensing, certification, and background checks. The other two offer
none of these protections and are Home Care Agencies and individual
caregivers, whether they provide services of housekeeping or other
non-medical support.

Nadereh Pourat, the UCLA center’s director of research and
author of the study stated, “Regulations within the private home
care industry might help establish standards for caregiving that can
ensure patient safety and quality of care.” This combined with
a mandatory background check should be a minimum. I don't think
licensing should be required, but a form should be filed with the
local law enforcement agency so that in case of a robbery, death,
fire, or other accident, they could know who might have been in the
residence.

Of course, the policy brief was funded by the Service Employee
International Union, and the Union of Long Term Care Workers. They
desire the licensing and union membership to put in their coffers.

Then those wanting regulation want them also for this reason.
Regulation could result in another important benefit, creating public
data that could be studied to better understand the quality of care
provided by home care agencies. Regulations by the state to create
standards of care and provide for background checks is
understandable, but for other purposes such as providing curiosity
data should not be the goal of regulations.

Other states would be wise to consider similar actions to create
standards.

24 September 2013

Whether the agriculture industry is actually pushing this or not
remains to be seen, but I do know many farmers are and actively doing
this. This being the spraying of insecticides on crops to kill
insects. It is unfortunate that honeybees and other pollinators (a
term that includes native bees, honeybees, birds, bats, and other
species of beneficial insects) are being affected by the
insecticides. I would be more inclined to believe that the
agricultural chemical business in cooperation with some of the large
agricultural industries is behind this killing of the honeybees.

Yes, and this would include the corn industry as they are ready to
increase their profits in high-fructose corn syrup to take the place
of honey.

Since 2006, up to 40% of the bee colonies in the US have suffered
Colony Collapse Disorder (CCD), in which honeybees die, disoriented,
far from their hives. The honeybee pollinates a third of all the
food we eat and contributes an estimated $15 billion in annual
agriculture revenue to the US economy alone. Fresh fruits and
vegetables, in particular, would simply not exist without honeybees.

“At least 143 million of the 442 million acres—that is,
nearly one-third—of US cropland is planted with crops treated with
these neuroactive insecticides, which are related to nicotine and are
highly toxic to bees. In the US, 100% of corn and canola is treated
with neonicotinoids, as well as 65% of soybeans and almost all
cotton, wheat, and smaller acreage crops. The pesticide expresses
itself through the plants’ pollen and nectar—the honeybee’s
favorite sources of food.

A recent Time magazine article notes a number of potential
reasons for CCD, including deadly bacteria and viruses—but nearly
all researchers agree that the main culprits are general chemical
exposure and pesticides (neonicotinoids in particular). A study of
honeybee pollen found nine different pesticides and fungicides in it
on average.”

“The agriculture industry doesn’t want their profitable
pesticides tampered with: there are over 1,200 pesticides currently
in use in the US, and many are made by the same companies that
engineer the crop seeds. So instead, Big Farma has begun creating
CAFO-like conditions for bees! It’s already happening on a small
scale; many argue that it may be the only alternative if we don’t
reign in the pesticides. “Bees may end up managed like cattle,
pigs and chicken, where we put them in confinement and bring the food
to them,” said one beekeeper and independent researcher quoted in
the Time article. “You…do feedlot beekeeping.””

Monsanto, surprise, is working on other GMO “fixes” for CCD as
well: they’re developing RNA-interference technology that will kill
one of the viruses thought to be killing the bees, the Varroa mite,
by interfering with the way the bees’ genes are expressed.

Because I have a very soft spot for bees and have kept bees as I
explained in my blog here, I would appreciate those living in the US
to support a new bill, HR
2692, “The Saving America’s Pollinators Act
of 2013,” that has been introduced in the House by Rep. John
Conyers, Jr. (D-MI) and Rep. Earl Blumenauer (D-OR). It would
suspend the use of neonicotinoids until the EPA can prove that the
insecticide “will not cause unreasonable adverse effects on
pollinators.” This proof of safety would need to be in the form of
published scientific research together with a completed field study.
Please contact your representative and urge his or her support of HR
2692.

23 September 2013

While I know a few doctors that will disagree with me, they are
the ones that don't use hand or equipment sanitation, refuse to wear
gloves, and in general ignore good safety standards. Some of these
same doctors are the ones insisting on touching patients and giving
them comfort according to them. I say comfort my !@@, I would rather
know that the stethoscope has been sanitized and see them wearing
gloves, than using an unsanitized stethoscope and not wearing gloves.

Another writer on the internet and a patient advocate agrees with
me. About two weeks ago now, I received an email from a wife asking
me if she had been wrong in insisting that the doctor wash his hands,
wear gloves in examining her husband who was in the hospital with
second degree burns over approximately 25% of his body and third
degree burns on about 5 percent.

She stated that she had to wear a special gown and gloves when
visiting her husband and she was aware of at least two other patients
in adjacent rooms that had MRSA and did not want it spread to her
husband. I emailed her back immediately and told her by all means
and stand between her husband and the doctor until she knew that the
doctor has sterilized his stethoscope, hands, and put gloves on. The
next day I received another email saying that the doctor had refused
to see her husband and had sent a nurse practitioner in while he
remained out in the hall. She stated that the NP had washed her
hands and gloved up before taking the stethoscope out of the sealed
packaging and then examined her husband.

After they had finished rounds the NP had returned to thank her
for correcting the doctor even though he refused to do any of what
she had requested. The NP stated as she left that he had seen both
MRSA patients before entering her husband's room. That made the wife feel much more positive about what she had
insisted on and she knew she would stand her ground until she was
sure there were no more MRSA patients on that floor. A week later
because of his improvement, he was transferred to another hospital
and she was thankful because everyone there followed sanitation rules
and had set the rules she was to watch for herself and other
visitors.

Yet the author of the blog that got me wrapped up in this, does
not like gloves and apparently other safety precautions and feels
that human contact is essential. I am sorry Dr. Sibert, but I think
I could not let you be my doctor or anesthesiologist in this case.
Just stay out of the operating room if you are afraid of wearing
gloves. To my way of thinking, you are the unclean person.

20 September 2013

This blog is derived from this blog written by Leslie Kernisan.
She makes many points that I can agree with and I list them first
followed by points I have.

Points of agreement: (Read the blog for Dr. Kernisan's
explanations.)

#1. If the 35-hour work week will mean more thorough and better
care, then make this happen.
#2. If the newly minted PCPs would truly take care of the
Medicare beneficiaries, this could be a great purpose.

The following are a listing of Dr. Kernisan's tasks she performs
regularly:

#3. Following up on 6+ chronic conditions and 12+ medications, in
an integrated whole-person fashion.
#4. Following-up on the work of multiple specialists, many of
whom hadn’t explained their thinking to the patient and family.
#5. Resolving the conflicts inherent in attempting to follow
clinical practice guidelines in patients with multiple conditions.
(See this JAMA article to understand how well intentioned practice
guidelines could cause serious problems for elderly patients.)
#6. Adjusting care plans as a function of goals and what seems
feasible for the patient. It is pointless to recommend chronic
disease management per best practices if it doesn’t seem feasible
to the patient and family.
#7. Explaining why certain commonly requested interventions –
antibiotics, diagnostic tests, specialty consults – might not be
helpful.
#8. Helping patients and families prioritize and identify a few
key health issues to work on at any given moment.
#9. Helping patients and families evaluate the likely benefits
and burdens of possible medical approaches.
#10. Helping patients and families cope with the uncertainties of
the future.
#11. Weighing in on family conflicts.

Now I have left out one factor that I feel doctors should not
become involved in and I am admitted tired to hearing them.

A point of disagreement and points not covered which need to be
considered

#2. The physician shortage will be here and is in many areas of
the country. It will take more than a decade to correct for this as
it is, even if the 35 hour-work-week becomes a reality.

#3. Let us stop squabbling about who may be able to help during
the shortage. Many doctors are urging their state medical boards to
prevent NPs, PAs, and Pharmacists from practicing unsupervised. Most
medical professional organizations are also filling the printed
pages, the internet, and air with their opposition to these
professions. Even if allowed to practice, there will still be a
shortage as many of them have gone the specialist route in search of
better wages. I feel fortunate that I have at present two NPs that I
see on a regular basis. Even though my state allows them to practice
independently, they still work under the supervision of MDs. My blog
-
http://bobsdiabetes.blogspot.com/2012/11/are-doctors-lobbying-themselves-out.html

#4. Many state medical boards have even limited PCPs and Family
Physicians and what they can practice, at the request of specialists
and their whining. Licensing boards are also limiting what some
para-professionals can and can not do. Because some doctors have
seen the need for education in the diseases of cancer, diabetes, MS,
and others, they have taken patients knowledgeable in these diseases
and spent time and occasionally money to train them as peer mentors
or peer-to-peer workers to assist them in educating their fellow
patients. A few state medical boards are now trying to even stop
this from happening. This blog -
http://diabetestopics.blogspot.com/2013/09/are-doctors-threat-to-their-own.html

#7. With the CMS program for assisting obese patients now
underway, most hospitals have established the weight-loss clinics
into the bariatric clinic to charge a fee to do an evaluation. This
evaluation is to determine if the bariatric clinic can convince these
patients to go the bariatric surgery route, thus gaining the surgeons
and hospital more money. If not, these patients are deemed unfit to
accomplish weight loss and not accepted into the program. This blog
-
http://bobsdiabetes.blogspot.com/2013/05/medicares-obesity-program-has-problems.html

#9. I have no idea if this is just my corner of the world, or is
more widespread, but when a patient questions a procedure, operation,
or medication, we are told we more than likely have cancer and need
to see the oncologist. Four doctors have thrown this in my face in
the last five months even after I have been given a clean bill of
health by a VA oncologist after two different days of tests and
procedures. Then when I tell them this, they just say that the VA is
not the most reliable. Only one doctor has thanked me for going
through the tests and eliminating the concern about my elevated white
cell count. No blog – yet.

#10. More doctors will need to enter the realm of contract
medicine to fulfill patients' needs, as doctors are more and more
becoming employees of hospitals. Because hospitals are driven by the
bottom line, little will change under the ACA and patients will
continue to be treated only when they have a disease, illness, or
injury requiring a doctor's care or that of a specialist. Heaven
help the patient with hypertension or diabetes if the hospitalist
decides to “tune-up” these patients when they are hospitalized
for an unrelated disease or illness. This blog -
http://diabetestopics.blogspot.com/2013/09/another-reason-to-be-careful-of.html

#12. Some patients are even excited about the prospect of being
able to see a doctor less often and become able to write their own
prescriptions. There would be some restrictions some patients will
not be able to meet. This blog - http://diabetestopics.blogspot.com/2013/07/some-patients-may-not-need-doctors-as.html

#13. Dr. Kernisan has covered “patient engagement” in her
blog -
http://thehealthcareblog.com/blog/2013/09/12/patient-engagement-on-metrics-and-meaning/
I am concerned about a problem I encounter all too frequently, the
doctor version of patient engagement. The doctor asks the questions
using his/her technical language and the patient is often unable to
answer because they do not understand the question. I lose out
because I do ask what a term means in lay language and the doctor
often fumbles my question and out the door goes patient engagement.
One part of patient engagement remains out in the cold because most
doctors will avoid allowing patients to access their medical records.
Hopefully, meaningful use will be denied for these doctors. Even
one of the physician clinics had signs up in every exam room about
access to EHRs and to ask the receptionist for a form and password.
When asked, the receptionist says that it is not available yet. My
translation – to let the inspector see this to pass meaningful use.

19 September 2013

The demand for primary care doctors is here now and will for many
years to come. With the demand for these doctors increasing in many
rural or less doctor dense areas, recruiters cannot fill the needs.
Merritt Hawkins, a national health care consulting and recruitment firm, speaks to some of the issues, but not all. This firm along
with two other staffing companies spans the lower 48 states and
includes rural and major metropolitan areas.

As we become more aware of the needs for doctors in the rural
areas and many underserved areas of medicine, all three recruiting
firms have found that hospitals and medical groups are continuing to
seek primary care physicians, nurses, and assistants. However, this
is the first year that the request for geriatricians out paced the
demand of previous years. This is also the first time that this
specialty has entered into the firms' top 20 of the most recruited.

Travis Singleton, senior vice president at Merritt Hawkins, stated
that, “It is interesting that our youngest doctors are treating
our oldest patients, but I think that some of it is just
reclassification, it was happening already.” Other
specialties, such as radiology and anesthesiology, despite being
among the most competitive and desired positions a decade ago, did
not make the top-20 list for 2013.

Dr. Atul Grover, an internist and chief public policy officer at
the Association of American Medical Colleges, says, “I think
people are starting to look at the market and get nervous, because of
Medicare payment changes that impact doctor's pay and the growing
emphasis on preventive medicine.”

I think the “growing emphasis on preventive medicine” has many
doctors making changes because they are afraid of preventive medicine
and know little about it, after having practiced only treating people
already ill or in need of treatment for a disease or chronic illness.

I have been made aware of two towns about an hour and one-half
distant of recently loosing two primary care doctors because their
agreement with the towns had been fulfilled. Both headed for
hospitals in larger cities where they will become hospitalists and at
a much higher wage and less hours.

Many doctors are taking different jobs to satisfy a work-life
balance and not the hectic almost 24/7 hours and paperwork of meeting
the needs of their current jobs. According to the three staffing
firms, hospitalists ranked third on the top 20 list.

Even with the health care law's attempt to curb the high cost of
emergency care, Merritt Hawkins reports an increased demand for
emergency department (ED) doctors. With patients finding fewer
primary care doctors available to meet their needs, patients will
continue to turn to the ED as a last resort or for convenience.

This points out the increasing need for doctors to be trained that
will serve in vulnerable communities and the need for incentives for
them to continue to practice in these communities. However, the
doctors that left these communities for large cities continue to
lobby to prevent NPs, PAs, and Pharmacists who have remained in these
communities from being able to practice unsupervised.

Therefore, it will be necessary for patients in these underserved
areas to lobby their state legislatures in opposition to the state
medical boards. Also these same patients in some communities to will
need to lobby for restrictions on telemedicine to be lifted. The
next decade will be interesting as the powers that exist now may see
their popularity disappear and be replaced by the very groups they
are muzzling now. And, I feel that the patients may play a large
part in this.

18 September 2013

Now lawmakers become concerned about the ability of the system to
protect personal health records and other private information. If
our congressional people would have been concerned about this when
they should have been concerned, maybe we would not need these
concerns now. Unfortunately, we still would, as Congress is not far
sighted enough, only to the next election and their reelection. That
is what all the posturing is about.

Yes, cyber security needs to be a concern, but this will never be
fully addressed, as Congress does not wish to offend the NSA because
they will be the largest consumer of the information. The data hub,
which is scheduled to go live October 1, will process names, dates of
birth, Social Security numbers, health conditions, and several other
pieces of personal information which at best will be very insecure.

Representative Patrick Meehan, a Pennsylvania Republican is on
target when he questioned how CMS completed its security assessment
nearly a month ahead of schedule after the agency had “for three
years failed to meet a single deadline.” Thehub, as
it is called, will store little information, instead accessing
information in other databases as needed. This means that once the
hub is breached; all the other sources will be accessible. Data
breaches at the hub would do “irreparable harm” to users, said
Stephen Parente, director of the Medical Industry Leadership
Institute at University of Minnesota. There hasn’t been enough
security testing on the hub, which is a “massive IT project with
literally no technical precedent,” he added.

Others are doing their best to downplay the security aspect and I
feel are doing more harm than good. It is not a matter of if, but
when the security breaches will happen. I say breaches and they will
probably come in rapid succession once they start and the U.S.
Department of Health and Human Services will probably do its best to
cover this up and this is where the concern needs to be.

17 September 2013

Hospitals are beginning to put standards and safety measures in
place to prevent hospital infections. With the Centers for Medicare
and Medicaid Services (CMS) and now other insurance companies
refusing to pay for hospital-acquired infections (HAIs), this has
forced the issue and hospitals are taking notice. When hospitals
have their bottom line at issue, they will take action, which is a
good thing for patients,

Although hospitals have balked at safety standards for decades,
being able to put a dollar value on associated costs could help
providers and payers justify investing in prevention measures. Even
with implementation of quality improvement initiatives, an estimated
$9.8 billion is spent each year for treating HAIs. This was the
finding of a study published online September 2 in JAMA Internal
Medicine.

Quoting from the abstract, “With surgical site infections
contributing the most to overall costs (33.7% of the total), followed
by ventilator-associated pneumonia (31.6%), central line–associated
bloodstream infections (18.9%), C difficile infections (15.4%), and
catheter-associated urinary tract infections (<1 i=""> This
is something that should not be ignored.1>

“"Not paying
for hospital-acquired infections or errors are an important part of
the movement toward paying for quality, not quantity, of care,"
Mitchell H. Katz, MD, director, Los Angeles County Department of
Health Services in California, concurs in an accompanying editorial.
This study, however, will enable hospital administrators to better
prioritize their spending by allowing them to compare the costs of
interventions with the savings accrued by avoiding infections.”

Patient safety should have always been a priority, but has not
been as long as hospitals were able to be reimbursed for their lack
of safety procedures.

16 September 2013

Apparently some doctors that are members of the Society of General Internal Medicine (SGIM) really do not care about their patients with
diabetes, only the money that they can receive for helping patients
develop the complications. Rather sad that doctors will work so hard
to cause harm to a group of patients. Don't get me wrong, as some of
the doctors that are members of the SGIM do not agree with their
policy listed in Choosing wisely.

I will continue to vent about those that do support "Don't
recommend daily home finger glucose testing in patients with Type 2
diabetes mellitus not using insulin.” This tells me that
they don't feel that the progression to complications can be stopped
and they do not want to continue trying to educate these patients.
Just including this on the list of choosing wisely shows they don't
care about these patients.

I have had an email from one of the doctors that has peer mentors
expressing his concern for how limited this will make his work. I
emailed him a copy of my blog that will appear on
http://bobsdiabetes.blogspot.com/
on September 17 and he agreed that he sees this as true, but
admitted he did not think insulin will be the only answer. He did think
that insulin will be one of the solutions. He is concerned that test
strips will disappear as a tool to assist in the management of
diabetes for those on oral medications. He is also concerned about
his fellow doctors and why they voted for this item.

I did email him back saying that these doctors will be considered
doing harm by me. His comment back was that I was on insulin and why
would I be concerned. I said because they are still people with
diabetes and deserve advocacy even if they don't realize the problems
coming at them. He does agree with the ideas that most type 2
patients on oral medications do need more than one test strip per day
and people on insulin do need more than three tests strips per day.

He commented that he will not prescribe any of the sulfonylureas
for people on Medicare or Medicaid that are limited to one test strip
per day. He will not be responsible for causing hypoglycemia when
the patient cannot test often enough to correct the episode. He does
ask patients to notify him immediately after if they have
hypoglycemia and correct it. He has his peer mentors reinforce this
in the education and works with these patients using email to
discover why they had an episode of hypoglycemia. He needs to use a
telephone for three patients because they do not have internet
service.

I did ask him if it may be a case that most doctors that are
members of SGIM did feel that diabetes was progressive and this may
have caused them to vote this way. He admitted that most of them
probably do think this, but have caused this by their attitude and
not doing any education. He felt that since he started using peer
mentors for education, the patients of his are doing significantly
better in managing their diabetes. He had been very uncertain about
using shared medical appointments (SMAs), but the fact that he has
peer mentors doing education while he sees patients individually in
another room is working very well and he has had only one patient
that walked out of a SMA. He concluded that he will carry on the
good cause and work to prevent his patients from being denied test
strips.

13 September 2013

Apparently, the drug companies are getting nervous about how long
statins are going to survive on the market. With the side effects of
causing diabetes, muscle wasting, and a few other problems, they
should be. Now they are studying new areas in hopes that this will
encourage people to remain on statins. Therefore, I read this article with a lot of skepticism and wondering if we will see more
studies confirming this study. I would also call attention to this article in Medscape declaring statins linked to musculoskeletal
injury and this article in WebMD linking statins to muscle/joint
problems.

Of course the authors did not call for further studies and we are
not told where or if the study was published since it may not be
peer-reviewed. This makes me even more a doubter of the results of
the study. Professor Kostis is the only person quoted in the article
and no educational institution or information is given about this
professor.

Professor Kostis states, “We therefore investigated the
relationship of statins and cataracts in a meta-analysis of 14
studies selected after detailed review of the medical literature. To
our knowledge, this is the first meta-analysis on the topic. The
meta-analysis included 2,399,200 persons and 25,618 cataracts. The
average duration of treatment was 54 months and average age was 61.”

Yes, this is a lot of people and cataracts, but I am not sure it
is of value. The more I analyze the report the more I have doubts
about the source, Stone Heart Newsletters. Professor Kostis is never identified or
associated with an institution. Is this a study and where was it
published? None of this information is included in the article

I will still blog about this, but only from the standpoint of this
being another poor example of research and coverage by a fair source. I made a comment to this at the bottom of the
article, but I have been ignored and received no answer. Therefore,
it is my belief that Big Pharma promoted the article and maybe even
the research and they do not wish to have the results confirmed or
denied. Sorry, but I can't accept the information as it is presented
and have to view the information as unreliable and even possibly a
farce. I also wonder if the benefits will now outweigh the risks

12 September 2013

When the first discussion took place in June 2012 and then when
the Diagnostic and Statistical Manual (DSM5) was published in
December 2012, I have been reading what has been published by other
writers and psychiatrists and psychologists have been saying or
writing. Finally, an author that I am able to understand and more
importantly agree with has written a blog about topics covered in
DSM. Much of the discussion on mental health really dehumanizes
patients and throws medications at patients when this may not be the
best.

I would ask that you read his blog for you own understanding, as I
am biased and pleased that he sees his patients as humans and how
they respond to positives given to them rather than just a diagnosis
and another medication to solve the problem. Medications may be
necessary for some mental health issues, but the wholesale
prescribing of medications will only lead to dependence on
medications and not a treatment, which will help the patient manage
their lives in a positive way.

Because of the way Dr. Dan Peters describes things, much of the
following will be quoted. “The questions that eat at me during
my day as a psychologist and at night as a person searching for
answers are:

#1. Is it possible to accurately identify mental
health “issues,” “illness,” or “disorders?” versus
extreme ranges within the sphere of the human condition? #2. Even if it is possible to identify these
conditions, does it determine the course of “treatment” or
“intervention?” #3. If so, is there a “treatment” for every
identified “condition?” #4. Does it mean there is a treatment that
works? #5. Do you need a diagnosis to get help?

Without going into detail about some of the changes in the
newest edition of the DSM, some diagnostic categories have been added
and some diagnosis “thresholds” have been lowered. This means
that you need fewer symptoms to “meet diagnostic criteria.” Here
are some examples of concerns with the new DSM-5:

#1. Temper tantrums will now be diagnosed as
Disruptive Mood Dysregulation Disorder #2. Normal forgetting will now be diagnosed as
Minor Neurocognitive Disorder #3. Gluttony will be diagnosed as Binge Eating
Disorder #4. Grief will be diagnosed as Major Depression #5. First time substance users and college
partiers will get a diagnosis of Substance Use Disorder #6. Everyday Worry will be diagnosed as
Generalized Anxiety Disorder”

The following is important and very meaningful. “And what’s
the number one treatment for all of these diagnoses? Medication. In
my 20+ years of working with children, adolescent, adults, and
families, I have found some simple and profound truths. First, if
you talk to people about what is wrong with them and causally assign
diagnostic labels to explain them, they feel badly about themselves
and it plays into their low self-esteem, self-confidence, and
self-worth. Next, if you help them to better understand their
strengths and weaknesses, and help them to develop tools to cope with
life, all of the aforementioned increases. Lastly, if you
focus on their strengths, rather than their “deficits,”
“disorders,” and “illness,” they become aware of neglected
and unknown aspects of themselves that they can and do use to
navigate life and meeting their goals.”Bold is my
emphasis.

“I ask that all mental health and medical providers,
educators, administrators, adults, and parents think critically when
making or accepting a diagnosis.Ask yourself:

#1. What is the purpose of making or accepting a
diagnosis? #2. Does it fit my or my client’s experience? #3. How will I explain the diagnosis to my
client? #4. What does this diagnosis mean to me
(client)? #5. Will this diagnosis help my client (help me)
achieve my goals? #6. Does the diagnosis explain a normal human
emotion or condition? #7. What are all the possible helpful
interventions? Can medication wait? #8. What is right with my client? What is right
with me (client)?

Those of us in the field of mental health and medicine have a
minimal obligation to do no harm. Further than that, we have an
obligation to improve the life conditions of our clients. Our
current mental health and insurance system makes this very hard, but
nothing in life that is worth anything is easy.”

I am very thankful he included “do no harm” in the above
paragraph and from the tenor of his blog, I understand him to mean
just that. Many of his colleagues may not care when they find it
easier to pass out pills. Don't misunderstand me, some mental health
issues do require medications, but as Dr. Peters points out,
medication does not solve all problems or should it be the end-all
for all mental health issues.

11 September 2013

With the ever growing population of people developing diabetes,
some are turning to legal remedies for stopping the tide and the role
that law can play in serving as an effective health tool. Honestly,
I had never thought legal remedies would be applied, but the more I
read about this study the more I realized that some of the most
useful legal remedies are not even mentioned in the press release.
When the American Diabetes Association has legal tools available to
use against discrimination, why should there not be other legal tools
available.

I may be criticized for this, but without legal remedies to force
doctors to become current in their knowledge, prevention, and
diagnosis of diabetes, patients will continue to bang their heads
against the wall. Doctors are the first line of defense and as long
as they continue to ignore diabetes, this diabetes epidemic will
continue. If stiff legal penalties are required to bring doctors
into the twenty-first century, so be it.

The law can be a critical tool for health improvement as long as
it does not jeopardize our freedom rights. Assessments reported in a
new study published in the American Journal of Preventive Medicine
indicates that federal, state, and local laws give only partial
support to guidelines and evidence-based interventions relevant to
diabetes prevention and control. Bold is my emphasis.

It is sad indeed that nearly 26 million people in the US have the
disease and about one-fourth are not aware they have diabetes.
Facing about 30 percent (about 1 in 3 people) having diabetes by
2050, it is time for action. Risk factors for type 2 diabetes
include limited access to nutritious food, limited opportunity for
physical activity, socio-economic conditions, and genetic
disposition. While many well-crafted guidelines and recommendations
for diabetes intervention exist, the incidence and prevalence of
diabetes continues to escalate.

Lead author, Anthony D. Moulton, PhD, Laboratory Science, Policy
and Practice Program Office, Office of Surveillance, Epidemiology,
and Laboratory Services, Centers for Disease Control and Prevention,
Atlanta, GA, states, "Laws, including statutes, ordinances,
and government agency rules and regulations, can support
interventions to prevent and control disease in various ways."

Dr. Moulton continues, "Laws can help shape environments
to reduce exposure to some type 2 diabetes risk factors and encourage
preventive behaviors, and laws can authorize or require provision of
prevention-oriented information designed to change the behaviors and
cultural norms that affect risk."

“Investigators analyzed the laws further to determine whether
they contained provisions that require, incentivize, or encourage
healthcare providers, insurers, employers, schools, child care
centers, restaurants, government agencies, and others, to take action
consistent with a given guideline.Investigators concluded that:

Implementation of guidelines for evidence-based
interventions for diabetes prevention and control is incomplete

Many opportunities exist for exploring uses of law to
improve adoption”

Dr. Moulton's conclusion is also worth quoting, "Laws that
are demonstrated to be effective, designed to support proven public
health and clinical interventions, and well implemented can give
crucial support to strategies that address public health priorities
and to wider adoption of evidence-based guidelines. Law is a key
tool for scaling and sustaining effective interventions at the
national level. Public health practitioners and policymakers
nationally can intensify their exploration and evidence-based
application of law to help slow and potentially reverse the
accelerating threat posed by the diabetes epidemic."

Dr. Moulton does not state this, but I think until doctors educate
themselves about diabetes and step up to the challenge, we will not
achieve any reduction in the diabetes epidemic. Doctors that make
statements, such as – “Watch what you eat, your blood sugar is a
little high,” or “Curb your sugar intake,” should be penalized
for not making a diagnosis or giving a complete description of
what the blood glucose readings mean for the patient. ONLY then will
we see a possible slowing of the number of diabetes cases. The 15
minute office visit or less, will do nothing to slow the diabetes
epidemic and blaming the patient needs to end.

About Me

I am enjoying life, despite diabetes type 2. I am retired and enjoying the time I have for writing and photography. I was diagnosed with type 2 on Oct 2003, on oral meds for 4 months and they were doing nothing to really improve my daily readings. By cutting my carbohydrates I received the most improvement, but still not enough. Then I requested insulin, even though I did not like the thought of needles. That brought about the biggest change and A1c's in the lower 6's and upper 5's. Now I am working at maintaining them under 6.0 and hopefully nearer 5.5.